Diabetes Ketoacidosis

DEFINITION:
  • It is a state of absolute or relative insulin deficiency aggravated by ensuing hyperglycemia,dehydration & acidosis producing derangements in intermediatory metabolism.
  • DKA is far more characteristic feature of type 1 Diabetes mellitus than of type 2 Diabetes mellitus.
  • Oxygen dissociation curve shifts to right in diabetic ketoacidosis
  • Cause of death in diabetic ketoacidosis in children is Cerebral edema
LAB DEFINITION:
  • Blood glucose level > 250 mg/dl
  • Blood pH < 7.3
  • Ketones in serum > 5 m.eq/L
  • High Anion Gap Acidosis 
MECHANISM:
  • The basic underlying mechanisms are:Absolute deficiency of circulating insulin.Secretion of insulin counterregulatory hormones; glucagon, adrenaline, cortisol and growth hormone. 
  • Increase in glucagon/insulin ratio, increased CAMP
  • This leads to disturbances in the following physiological processes:
  1. Glucose utilization (hyperglycemia).
  2. Proteolysis ( amino acids, glutamine and alanine).
  3. Lipolysis ( glycerol and FFAs).
  4. Glycogenolysis (breakdown of muscle glycogen lactate).
  5. Gluconeogensis (glutamine & alanine & glycerol & lactate are the precursors).
INITIATING OR TRIGGERING FACTORS:
  • Infection
  1. Pneumonia & UTI most commonly

  • Inadequate use of insulin
  1. Not taking insulin.

  • Emotional stress
  • Drugs:
  1. Corticosteroids
  2. Antihistamines
  3. Thiazide Diuretics
  4. Pancreatitis
CLINICAL FEATURES:
  • Symptoms of DKA:
  1. Classic symptoms of hyperglycemia: short period of time:

  • Polyuria, polydipsia, weight loss and thirst.
  • Other symptoms:
  1. General weakness, malaise and lethargy.
  2. Nausea, vomiting and abdominal pain.
  3. Perspiration.
  4. Disturbed consciousness and confusion.

  • Symptoms of underlying infections or other conditions; fever, abdominal pain, dysuria, chest pain…etc
  • General signs: Ill appearance and disturbed consciousness.
  • Orbital mucormycosis is a complication of diabetic ketoacidosis
  • Signs of dehydration:
  1. Skin: Dry, hot, flushed, and loss of skin turgor.
  2. Tongue: Dry (sometimes woody tongue).
  3. Eyes: Sunken eyes and dark circles under the eyes.

  • Vital signs:
  1. Tachycardia, hypotension and tachypnea.

  • Specific signs:
  1. Ketotic breath: A strong, fruity breath odour (similar to nail polish remover or acetone).
  2. Acidotic breath (Kussmaul's respiration): deep and rapid.
  3. Abdominal tenderness.
DIAGNOSIS:
  • You should suspect DKA if a diabetic patient presents with:Dehydration.
  • Acidotic (Kussmaul’s) breathing, with a fruity smell (acetone).
  • Abdominal pain &\or distension.
  • Vomiting.
  • Decreased Bicarbonate is seen in diabetic ketoacidosis
  • An altered mental status ranging from disorientation to coma.
  • PITFALLS IN DKA:
  1. High WCC: may be seen in the absence of infections.
  2. BUN: may be elevated with prerenal azotemia secondary to dehydration.
  3. Creatinine: some assays may cross-react with ketone bodies, so it may not reflect true renal function.
  4. Serum Amylase: is often raised, & when there is abdominal pain, a diagnosis of pancreatitis may mistakenly be made
Factors                     DKA Starvation
pH                            ↓ normal
Plasma glucose          ↑ normal
Glycosuria                 + + ----
Total plasma ketones ↑↑     Mild ↑
Anion gap                  ↑      Mild ↑
Osmolality                 ↑      normal

TREATMENT:

  • General measures:
  1. Airway and O2 inhalation if needed.
  2. IV line.
  3. Urinary Foley's catheter (if in shock).
  4. NGT (Nasogastric Tube): to avoid gastric dilatation and protection from aspiration .
  5. Thrombosis prophylaxis: 5000 units of heparin SC/12 hours.
  6. Empiric use of 3rd generation cephalosporin antibiotics.

  • Specific measures:
  1. Successful therapy of hyperglycemic crises requires the administration of:

  • Fluids:
  • Correct volume deficit and hypotension.
  • Improve tissue perfusion.
  • Improve insulin sensitivity (¯insulin counterregulatory hormones).
  • Improve glomerular filtration rate:
  • ↑ excretion of large amount of glucose in urine.
  • Clears hyperketonemia.
  • Correct metabolic acidosis.
  • Regular Insulin: Reversal of metabolic abnormalities :
  • Corrects hyperglycemia.
  • Inhibits ketogenesis.
  • Potassium: Prevents complications associated with hypokalemia.
  • Somatostatin :inhibiting glucagon & GH release.(These counter regulatory hormones are increased in DKA)
Exam Question:of
  • High Anion Gap Acidosis is seen in Diabetic Ketoacidosis
  • A patient with diabetic ketoacidosis in coma should be given immediate insulin therapy with Potassium supplementation
  • Increase in glucagon/insulin ratio, increased CAMP and increased blood glucose is seen in diabetic ketoacidosis
  • Decreased Bicarbonate is seen in diabetic ketoacidosis
  • Oxygen dissociation curve shifts to right in diabetic ketoacidosis
  • Orbital mucormycosis is a complication of diabetic ketoacidosis
  • Somatostatin is used in Diabetic ketoacidosis
  • The drug of choice for managing hyperglycemia in diabetic ketoacidosis is Regular insulin
  • Cause of death in diabetic ketoacidosis in children is Cerebral edema
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